ADENOIDES

From Big Medical Encyclopedia

ADENOIDES (Greek aden — gland and eidos — a look; synonym: adenoid vegetations, adenoid vegetations) — a pathological hypertrophy of «third», or pharyngeal (nasopharyngeal), almonds (tonsilla pharyngea) which is in the arch of a nasopharynx. This almond together with lingual and palatine tonsils is a part of lymphadenoid pharyngeal «ring». Thickness of a pharyngeal almond on average of 5 — 7 mm, width is 20 mm and length is 25 mm. Cracks between rollers have an appearance rectilinear or on the periphery dugoobrazno of the curved grooves parallel each other or meeting kzad. The deepest, located on the centerline groove comes to an end kzad with the impression carrying the name of a pharyngeal bag (bursa pharyngea). The pharyngeal almond is developed only at children's age, approximately from 12 years it begins to decrease in sizes. By 16 — 20 years only the small remains of lymphadenoid fabric usually remain, and at adults usually there comes its full atrophy.

The pharyngeal almond, mentioning about a cut is available even in G. D. Santorini's work, is in more detail described by Lushka (N. Luschka), by name to-rogo with quite often call Lushki's almond. N. I. Pirogov pointed that between a vault of the farynx and the main part of an occipital bone there is accumulation of mucous follicles and that in them it is necessary to look for primary center of retropharyngeal abscesses.

In the patient ADENOIDES were found for the first time by Chermak (J. N. Czermak, 1860) by means of the method of a back rinoskopiya offered them. But the fullest clinical description on the basis of 48 observations was given by the Danish doctor Meyer (N. to W. Meyer) in 1873.

The symptomatology of adenoid vegetations was significantly enriched after communication between diseases of a nose and the general disturbances in an organism was proved. By researches of virologists it was revealed that pharyngeal and palatine tonsils are a tank of both latent, and epidemic adenoviruses where they create the constant center of infection and Sep of a sibilization, periodically causing not only aggravations of a chronic adenoiditis, but also repeated acute respiratory diseases and aggravations of bronchopulmonary processes.

Adenoid vegetations are of great importance in pathology of upper respiratory tracts and an acoustic organ. Existence And. causes not only local frustration in the form of difficulty of nasal breath, a hearing disorder, changes of a voice, but often reflects adversely on the general condition of an organism.

Adenoides. Fig. 1. Sagittal cut of a nose and nasopharynx. Fig. 2. Back rinoskopiya

ADENOIDES are formed as a result of pathological growth of lymphadenoid fabric of a pharyngeal almond (tsvetn. fig. 1).

At a hypertrophy the pharyngeal almond extends kpered to a postnaris and a share, a kzada to a pharyngeal hillock (tuberculum pharyngeum), in the parties — to pharyngeal pockets (rozenmyullerovy poles) and bells of acoustical (eustachian) pipes. Sizes A. (a little conditionally) define by a back rinoskopiya (tsvetn. fig. 2).

Distinguish three extents of growth of pharyngeal almonds: The I degree — And. cover an upper part of a share, the II degree — upper two thirds of a share and the III degree — the big adenoides covering completely or almost completely a share.

And. are observed equally often at children of both sexes usually aged from 3 up to 10 years, but they meet also as in the first months and years of life, and after puberty and (as an exception) at elderly and even senile age. Among ambulatories (at joint reception of adults and put) percent suffering And. reaches to 6 — 7; in children's out-patient clinics this figure is much higher.

An etiology

the Reasons of a hypertrophy of a nasopharyngeal almond are various. Often rapid growth of ADENOIDES is result of the children's infectious diseases (measles, whooping cough, scarlet fever, diphtheria, flu, etc.) causing inflammatory reaction of a mucous membrane of a nasal cavity and lymphadenoid tissue of a nasopharynx. Unfavorable living conditions (the crude, dark and badly aired rooms, qualitatively and quantitatively a hyponutrient etc.) reduce protective functions of an organism, often conduct to the acute and chronic inflammations of upper respiratory tracts contributing to development And.

Pathological anatomy

Adenoides — the opukholepodobny mass of light pink color which is located on the wide basis in the field of a vault of the farynx. The pulled surface they sometimes remind a cock crest (fig. 1). Except ground mass And., great value have the side educations resulting from a hypertrophy of the follicular device of a mucous membrane of a throat; they quite often fill pharyngeal pockets and mouths of acoustical pipes. At children at the beginning of development And. happen usually soft, testovato-friable consistence. With age and as a result of repeated inflammations the atrophy of an adenoid tissue begins and respectively there occurs growth of connecting fabric. And. at the same time gradually become more dense and decrease in volume. At the same time their color — from red to light pink or gray-pink changes. At a histologic research remote And. in an adenoid tissue signs of an inflammation are found more often. Irrespective of expressiveness of a hyperplasia of lymphadenoid fabric in 75 — 80% of cases and more various forms of chronic are defined adenoiditis (see).

A clinical picture

Symptoms of ADENOIDES are very various. The main of them — a periodic or constant mortgaging of a nose with the plentiful allocations filling the nasal courses that breaks blood circulation in nasal cavities and nasopharynxes. There are developments of stagnation in a nose and even in his adnexal bosoms, leading to chronic swelling and an inflammation of a mucous membrane of a nose, especially back ends of nasal sinks, and to plentiful accumulation of dense viscous slime. Often chronic cold develops. As a result of the complicated nasal breath children with And. sleep with an open mouth, their dream usually happens uneasy, quite often is followed by loud snore and even attacks of suffocation owing to retraction of a root of language at the drooped mandible; children get up sluggish and apathetic in the morning, is frequent with a headache.

Fig. 1. Remote adenoides.

At big And., filling all vault of the farynx, and owing to swelling of a mucous membrane of a nose disturbances of phonation are noted, the voice loses the sonority, accepts a shade hard of hearing — the closed twang (rhinolalia clausa).

Closing openings of acoustical pipes, And. lead sometimes to a considerable hearing impairment, especially during acute cold. The periodic hearing impairment often causes absent-mindedness and a carelessness of the child. Because of a hearing impairment children of early age sometimes cannot long learn to speak or hardly seize the speech. At a combination of Ampere-second exudative diathesis dense viscous allocations from a nose cause irritation of skin, swelling of an upper lip, and sometimes and eczematic defeat of an entrance to a nose. Because at the child the mouth is constantly open, its mandible droops, nasolabial folds smooth out. Long breath through a mouth can lead to various anomalies of growth of a skeleton of the person. Especially considerably the shape of an upper jaw changes: it is as if squeezed from sides, extended and it is represented wedge-shaped, the hard palate takes the form of the so-called Gothic arch. The wrong arrangement of teeth is sometimes noted: upper cutters considerably act in comparison with lower forward or are located in two ranks as they do not find room in a narrow alveolar shoot of an upper jaw.

Fig. 2. Typical look at adenoides.

Change of a shape of a face and upper jaw, constantly open mouth, sluggish and indifferent expression (fig. 2) received the name of the adenoid person, or an external adenoidism (habitus adenoidicus, facies adenoidica).

Long difficulty of nasal breath can lead to maldevelopment of a thorax. Many frustration caused And., it is necessary to treat but only as a result of the mechanical obstacle complicating nasal breath and breaking blood circulation and a lymph drainage in a nasal cavity but also as result of the reflex influences caused by irritation of the receptors which are stuffed up in adenoid vegetations.

Features of disease at various age. At newborns of a postnaris have the round form, the cavity of a nasopharynx is lower therefore a postnaris is closed by adenoid vegetations more, than at adults. Babies transfer difficulty of nasal breath heavier, than children of advanced age. The uneasy dream, disturbance of the act of suction leads to underfeeding; night cough or attacks of a false croup is quite often observed. Infected And. at children of chest age often are the reason of development of bronchitis and bronchial pneumonia.

At children of advanced age the headache is often noted, edges can arise owing to the developments of stagnation complicating outflow of a venous blood and lymph from a head cavity. The bed wetting which is observed sometimes, the phenomena of a laryngospasm, the choreoid movement of face muscles (grimace), asthmatic attacks etc. have reflex character.

Dysfunctions went. - kish. a path (small appetite, repeated vomiting, locks and ponosa) and the dikhaniye (insufficient intake of oxygen) lead to an anemia and emaciation (adenoid cachexia).

At breath the cold undamped and insufficiently cleaned air arriving through a mouth leads complications to frequent catarrhal diseases — cold, to quinsies, laryngitis, tracheitises and bronchitis. The descending katara of upper respiratory tracts especially easily recur in the presence of the infected adenoid growths. Complications arise also from ears. The acute adenoidites which are the frequent reason of acute average otitises are especially dangerous. In all cases of a chronic inflammation of an acoustical pipe, catarral and chronic purulent average otitis it is necessary to investigate carefully a nasopharynx since existence even of small ADENOIDES quite often is the reason of a chronic course of average otitises.

The diagnosis

Recognition of ADENOIDES usually does not present great difficulties. In certain cases on the basis of outward of the child it is possible to suspect existence And., however the final diagnosis is made only after a back rinoskopiya and palpation by a finger of a nasopharynx. The back rinoskopiya not always works well, especially at small children; in these cases it is necessary to apply a research of a nasopharynx a finger. For a research of a nasopharynx a finger of the child seat on a chair; the assistant sits opposite, holding hands of the patient and distracting his attention. The doctor costs behind, to the right of the patient, an index finger of the left hand it slightly presses the left cheek of the child between teeth to warn a sting of a finger, then the bystry movement enters disinfected index (or average) a finger of the right hand on a back wall of a throat up to a vault of the farynx. Turning the end of a finger in different directions, the doctor feels a vault of the farynx, a postnaris, the back ends of a sink, pipe rollers and pharyngeal pockets. The research should be conducted quickly, during 3 — 5 sec. Quite often at a research anomalies of the arch and a back wall which cannot be established with such accuracy at a back rinoskopiya are defined by a finger of a throat. In some cases apply also X-ray inspection: in pictures in various projections And. konturirutsya against the background of an air column of a nasopharynx. The data obtained at a research need to be considered during operation.

At to differential diagnosis it must be kept in mind that difficulty of nasal breath can be caused by a variety of reasons: curvature of a nasal partition, hypertrophy of the back ends of the lower nasal sinks, nasal polyps, choanal polyp, benign or malignant tumors (fibroma, endothelioma, sarcoma of a nasopharynx). Strong likeness with And. so-called fibroma of youthful age has sometimes (during initial development). At suspicion of a tumor, and also during the recuring remote And. it is necessary to make a histologic research. Acute inflammatory processes in a nasopharynx, acute inflammations of fabric of a pharyngeal almond (an acute adenoiditis), retropharyngeal abscess proceed at an elevated temperature that allows to differentiate easily them from And.

The forecast

the Forecast at ADENOIDES in most cases favorable, it worsens if there are considerable constitutional and hereditary changes in a type of a diffusion hyperplasia of the lymphadenoid device of a throat.

Treatment

Treatment growths of a pharyngeal almond, especially at II and III degrees, as a rule, surgical.

Indications to operation the absolute value of ADENOIDES, how many the disturbances caused by them serve in an organism not so much. At babies indications to an adenotomy is chronic cold, sharply expressed difficulty of nasal breath, and also the repeating adenoidites (an acute inflammation of giperplazirovanny adenoid fabric) which are especially followed by acute recurrent otitises. At children of advanced age need for an adenotomy arises at persistent hyper secretory nasmorka, permanent disturbances of nasal breath and diseases of ears. At adults need for an operative measure most often arises at complications from ears. At the same time it is necessary to consider not only size A., but also in what measure they are a source of an infection.

Contraindications to operation are: the general weakening of an organism after recently postponed acute infectious diseases (flu, measles, scarlet fever, quinsy), diseases of blood (in particular hemophilia). Before operation, in addition to the general inspection, it is necessary to exclude inborn syphilis, tuberculosis, the expressed diseases of cardiovascular system. It is not necessary to do acute inflammatory respiratory diseases operation, at suspicion of an infectious disease, and also during epidemics (flu, etc.).

Technology of operation

Just before operation it is necessary to make bulk analysis of blood, a blood analysis on coagulability, definition of a bleeding time and quantity of thrombocytes, and also a research of slime from a nose and a throat on a diphtheritic carriage of bacilli.

To small children, in view of the fact that operation is short-term also a maloboleznenna, anesthesia is not applied, if necessary resort to premedication various combinations analgetic, neuroplegic and antihistamines; resort to an anesthesia seldom — more often at an adenotonzillektomiya.

Fig. 3. Removal of adenoides.

To children of advanced age grease the most sensitive sidewalls of a nasopharynx through a nose and a mouth of 1 — 2% with solution of Dicainum or 5% solution of cocaine with adrenaline (some authors apply instead of greasing spraying of a stomatopharynx the same solutions). It is better to make operation in the morning on an empty stomach. For operation most often use ring-shaped knives — Bekmann's adenotomes (see. Otorhinolaryngological tools ), who are five sizes according to the size of a nasopharynx. Some doctors prefer for removal And. nasopharyngeal nippers of Matte, Denkera or adenotomes with a guillotine like Shittsa. Tools for removal And. choose, proceeding from features of a shape of a nasopharynx and the location And. at this patient.

At operation for the best fixing of the child put on knees of the assistant who clamps between knees of a leg of the patient, depriving of it an opportunity to lean against a floor; one hand it holds the head, and another — densely takes hands of the patient. It is better to wrap small children in a sheet. The pallet otdavlivat language from top to bottom and enter an adenotome for a soft palate, establish it strictly on the centerline, advance up kpered, concerning the rear edge of a nasal partition, further press above to the arch of a nasopharynx. Then the bystry movements in front back on a dome and further from top to down on a back wall of a nasopharynx cut off And. (fig. 3). If there are scraps of fabric which are hanging down in a throat, then they are skusyvat a conchotome or cut off curved scissors. Removal And. usually is followed by bleeding, a cut quickly stops. After cleaning of a nasal cavity with an alternate otsmarkivaniye (or a pandiculation of air from a nose to a throat) blow through a nose disinfecting powder (e.g., mix of streptocides). If operation was made in out-patient clinic, then the child is detained on 1 — 2 hour then, having convinced of absence of bleeding, allow to go home. During the first 2 — 3 days after operation the bed rest and 2 — 3 more days room is recommended. Temperature of food shall be within 18 — 20 °. Cleaning of the room where there is a patient, is made in the wet way.

Complications

Complications can arise both during operation, and in the postoperative period. During operation at insufficient fixing of the patient and his active resistance rough carrying out the end of an adenotome can lead to wound of various parts of an oral cavity, a soft palate, a separation of a uvula (palatal) etc. In the nasopharynx the rear edge of a share, the back ends of the lower sinks, rollers of acoustical pipes can be exposed to such injury. The beginning surgeons usually spend the end of an adenotome insufficiently highly therefore only the bottom of a hypertrophied almond is remote. Sometimes too strong pressing made by sharply perfected knife conducts to the fact that are remote and deeper fabrics, up to a prevertebral fascia. Cases when the adenotome cut off a bone plate of a body of the speaker of a vertebra (so-called vertebra prominens) are described. Remote And. can get into a nasal cavity or to be aspirirovana in a throat; at operation without anesthesia they right there jump out a strong potassium push. Sometimes And. are swallowed by patients.

The most frequent complication is the postoperative bleeding arising directly after operation or several hours later or even one — three days. In large part cases the scraps which are not removed completely are the reason of such bleeding And. In certain cases bleedings the repeated scraping of a nasopharynx an adenotome is necessary.

Also rejection of a wound scab can be the cause of later bleedings that is usually observed for the 4th or 5th day after operation, especially at restless children. From the general actions appoint drugs of calcium, administration of serum or hemotransfusion. At severe bleedings (in rare instances) it is necessary to do a back tamponade. The tampon entered into a nasopharynx constitutes danger to a middle ear, and therefore longer 24 hours it is not necessary to leave it. After removal And. rather often in the first 2 — 3 days after operation small rise in temperature (to 37 °) which does not constitute danger is observed. Only temperature increase higher than 38 ° within several days shall cause fears. Temperature increase to 38 ° occurs sometimes at an acute inflammation regional limf above. nodes or an acute inflammation of a middle ear which are quite often observed after an adenotomy. It is better to hospitalize such patients. Diphtheria of a wounded surface, purulent meningitis, sepsis after an adenotomy were observed in some cases by a number of authors. The tubercular meningitis which arose during the traumatizing not recognizable tuberculous focus in an almond belongs to rare complications of an adenotomy. Prevention of such complications is careful and comprehensive inspection of patients before operation.

A recurrence

the Recurrence of ADENOIDES at correctly made operation is observed seldom (approximately in 2 — 3% of cases), is preferential at early children's age. During incomplete removal And., especially at early age, the recurrence of a disease can be observed.

If operation of an adenotomy is contraindicated, it is possible to resort to a roentgenotherapy.



Bibliography: Likhachev A. G., Konstantinova N. P. and Ritova V. V. A role of adenoviruses in an etiology and a pathogeny of adenoid diseases and adenoidites, Vestn. otorinolar., t. 35, M 3, page 3, 1972, bibliogr.; The multivolume guide to otorhinolaryngology, under the editorship of A. G. Likhachev, t. 3, page 208, M., 1963, bibliogr.; Bridge S. I. and Marchenko E. D. Adenoid growths at children of the first year of life, Kiev, 1970, bibliogr.; Surgical diseases of a nose, adnexal bosoms and a nasopharynx, under the editorship of Ya. S. Temkin and D. M. Rutenburga, page 568, M., 1949; Linder - Agopvop of S. Adenoids, Uppsala, 1970, blbliogr.

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